Low Case Fatality Rate Research Articles

Bundibugyo ebolavirus replicates to lower viral titer in innate immune cells (VIR2P.1171)

Abstract The current Zaire ebolavirus (ZEBOV) epidemic in West Africa reinforces the need for effective vaccines and therapeutics that protect against all species of ebolavirus (EBOV). To achieve this, we characterized the effect of virus infection of macrophages and dendritic cells using the recently discovered Bundibugyo ebolavirus (BEBOV). BEBOV infection of humans and nonhuman primates has a lower case fatality rate, differing clinical presentations, and longer time to death compared to ZEBOV. More importantly, survivors and non-survivors of BEBOV have detectable antibodies against BEBOV, indicating that BEBOV interaction with immune cells may differ from ZEBOV. To better understand BEBOV pathogenicity and determine the effects of BEBOV on macrophages and dendritic cells, we performed growth curves and cell characterization in monocyte-derived dendritic cells and PMA-induced THP-1 macrophage-like cells. Over 96 hours, virus production was measured by virus titer, flow cytometry, and qRT-PCR. During monocyte derived dendritic cell experiments, cell surface markers were characterized over time to determine changes induced by EBOV infection. In all cell types tested, BEBOV grows to a lower viral titer. This may play an important role in the overall pathogenesis of BEBOV. Understanding the systemic immune response to BEBOV will aid in determining the mechanism of decreased pathogenesis and identify antiviral targets to be used in developing broad spectrum EBOV therapeutics.

Incidence, Severity and Prognosis Associated with Hyponatremia in Dogs and Cats

BackgroundHyponatremia is a common electrolyte abnormality in human patients and is associated with substantial morbidity and death. The incidence and importance of hyponatremia in dogs and cats has not been determined.Hypothesis/ObjectivesTo describe the incidence of and prognosis associated with hyponatremia in dogs and cats at a university teaching hospital.AnimalsOf 16,691 dogs and 4,211 cats with measured blood or serum sodium concentration.Methods Retrospective study. Medical records of animals with a blood or serum sodium concentration measured during a 60‐month period were reviewed to determine the severity of hyponatremia and its associated fatality rate. Cases with moderate (11–15 mmol/L below the reference range) or severe hyponatremia (≥16 mmol/L below the reference range) were further reviewed.ResultsOf 4,254 dogs (25.5%) and 2,081 cats (49.4%) were diagnosed with hyponatremia. Case fatality rates of dogs and cats with hyponatremia were 13.7% and 11.9%, respectively, compared to 4.4% and 4.5% with a normal blood or serum sodium concentration (P < 0.0001). The magnitude of hyponatremia was linearly associated with a higher case fatality rate (P < 0.0001). Hyponatremia was associated with a lower case fatality rate than hypernatremia in the same population. Among the animals with moderate or severe hyponatremia, 92.1% of dogs and 90.6% of cats presented with community‐acquired hyponatremia, and 7.9% of dogs and 9.4% of cats developed hospital‐acquired hyponatremia.Conclusions and clinical importanceHyponatremia was found commonly in this population and was associated with increased case fatality rate. Presence and severity of hyponatremia might be useful as a prognostic indicator.

Underlying effect of age on outcome differences in arteriovenous malformation-associated intracerebral hemorrhage

Brain arteriovenous malformations (AVM) are the most common cause of intracerebral hemorrhage (ICH) in young adults. Although previous studies have found that the mortality and morbidity of ICH due to AVM (AVM-ICH) is lower than in spontaneous ICH, it is unclear whether the more favorable prognosis is directly related to the presence of the vascular malformation. We included 34 patients with AVM-ICH and 187 with spontaneous intracerebral hemorrhage (sICH) due to either hypertension or cerebral amyloid angiopathy. Patient data were obtained from the prospective Intracerebral Hemorrhage Outcomes Project, which enrolls ICH patients admitted to Columbia University Medical Center. Using ICH etiology (AVM-ICH or sICH) and previously verified predictors of ICH outcome, two multivariate analyses were performed with and without age to compare the odds of death at 3months and the functional outcome. Although mortality in AVM-ICH group was lower than the sICH group (20.6% versus 43.3%, respectively), this value was only significant when age was excluded (p=0.017) and lost its significance when we controlled for age (p=0.157). There was an analogous loss of significance with functional outcome using the modified Rankin Scale. In conclusion, our data suggests that the previously observed lower case fatality rate and more favorable functional outcomes in the AVM-ICH group compared to the sICH group may largely be the result of age.

Clinical Illness and Outcomes in Patients with Ebola in Sierra Leone

BackgroundLimited clinical and laboratory data are available on patients with Ebola virus disease (EVD). The Kenema Government Hospital in Sierra Leone, which had an existing infrastructure for research regarding viral hemorrhagic fever, has received and cared for patients with EVD since the beginning of the outbreak in Sierra Leone in May 2014.MethodsWe reviewed available epidemiologic, clinical, and laboratory records of patients in whom EVD was diagnosed between May 25 and June 18, 2014. We used quantitative reverse-transcriptase–polymerase-chain-reaction assays to assess the load of Ebola virus (EBOV, Zaire species) in a subgroup of patients.ResultsOf 106 patients in whom EVD was diagnosed, 87 had a known outcome, and 44 had detailed clinical information available. The incubation period was estimated to be 6 to 12 days, and the case fatality rate was 74%. Common findings at presentation included fever (in 89% of the patients), headache (in 80%), weakness (in 66%), dizziness (in 60%), diarrhea (in 51%), abdominal pain (in 40%), and vomiting (in 34%). Clinical and laboratory factors at presentation that were associated with a fatal outcome included fever, weakness, dizziness, diarrhea, and elevated levels of blood urea nitrogen, aspartate aminotransferase, and creatinine. Exploratory analyses indicated that patients under the age of 21 years had a lower case fatality rate than those over the age of 45 years (57% vs. 94%, P=0.03), and patients presenting with fewer than 100,000 EBOV copies per milliliter had a lower case fatality rate than those with 10 million EBOV copies per milliliter or more (33% vs. 94%, P=0.003). Bleeding occurred in only 1 patient.ConclusionsThe incubation period and case fatality rate among patients with EVD in Sierra Leone are similar to those observed elsewhere in the 2014 outbreak and in previous outbreaks. Although bleeding was an infrequent finding, diarrhea and other gastrointestinal manifestations were common. (Funded by the National Institutes of Health and others.)

Disease associated with equine coronavirus infection and high case fatality rate.

BackgroundEquine coronavirus (ECoV) is associated with clinical disease in adult horses. Outbreaks are associated with a low case fatality rate and a small number of animals with signs of encephalopathic disease are described.ObjectivesThe aim of this study is to describe the epidemiological and clinical features of two outbreaks of ECoV infection that were associated with an high case fatality rate.Animals14 miniature horses and 1 miniature donkey testing fecal positive for ECoV from two related disease outbreaks.MethodsRetrospective study describing the epidemiological findings, clinicopathological findings, and fecal viral load from affected horses.ResultsIn EcoV positive horses, 27% (4/15) of the animals died or were euthanized. Severe hyperammonemia (677 μmol/L, reference range ≤60 μmol/L) was identified in one animal with signs of encephalopathic disease that subsequently died. Fecal viral load (ECoV genome equivalents per gram of feces) was significantly higher in the nonsurvivors compared to animals that survived (P = .02).Conclusions and Clinical ImportanceEquine coronavirus had a higher case fatality rate in this group of miniature horses than previously reported in other outbreaks of varying breeds. Hyperammonemia could contribute to signs of encephalopathic disease, and the fecal viral load might be of prognostic value in affected horses.

Evaluation of targeted mass cholera vaccination strategies in Bangladesh: a demonstration of a new cost-effectiveness calculator.

Growing interest in mass vaccination with oral cholera vaccine in endemic and epidemic settings will require policymakers to evaluate how to allocate these vaccines in the most efficient manner. Because cholera, when treated properly, has a low case fatality rate, it may not be economically feasible to vaccinate an entire population. Using a new publicly available calculator for estimating the cost-effectiveness of mass vaccination, we show how targeting high-risk subpopulations for vaccination could be cost-effective in Bangladesh. The approach described here is general enough to adapt to different settings or to other vaccine-preventable diseases.

Pregnancy-associated listeriosis in England and Wales

Listeriosis is a rare but severe foodborne disease with low morbidity and high case-fatality rates. Pregnant women, unborn and newborn babies are among the high-risk groups for listeriosis. We examined listeriosis cases reported to the enhanced surveillance system in England and Wales from 1990 to 2010 to identify risk factors influencing outcome. Cases were defined as pregnancy-associated if Listeria monocytogenes was isolated from a pregnant woman or newborn infants aged <28 days. Of the 3088 cases reported, pregnancy-associated listeriosis accounted for 462 (15%) cases and 315 cases resulted in a live birth. Several factors were identified as affecting the severity and outcome of listeriosis in pregnancy in both mother and child including: presence or absence of maternal symptoms, gestational age at onset of symptoms, and clinical presentation in the infant (meningitis or septicaemia). Deprivation, ethnicity and molecular serotype had no effect on outcome.

Clinical Features and Outcome in Children with Severe Plasmodium falciparum Malaria: A Meta-Analysis

BackgroundAlthough global malaria mortality is declining, estimates may not reflect better inpatient management of severe malaria (SM) where reported case fatality rates (CFRs) vary from 1–25%.MethodsA meta-analysis of prospective studies of SM was conducted to examine i) whether hypothesized differences between clinical features and outcome in Melanesian compared with African or Asian children really exist, and ii) to explore temporal changes in overall and complication-specific CFRs. The proportions of different SM complications and, overall and complication-specific CFRs were incorporated into the meta-analysis. Adjustments were made for study-level covariates including geographic region, SM definition, artemisinin treatment, median age of participants and time period.FindingsSixty-five studies were included. Substantial heterogeneity (I 2>80%) was demonstrated for most outcomes. SM definition contributed to between-study heterogeneity in proportions of cerebral malaria (CM), metabolic acidosis (MA), severe anemia and overall CFR, whilst geographic region was a significant moderator in for CM and hypoglycemia (HG) rates. Compared with their African counterparts, Melanesian children had lower rates of HG (10% [CI95 7–13%] versus 1% [0–3%], P<0.05), lower overall CFR (2% [0–4%] versus 7% [6–9%], P<0.05) and lower CM-specific CFR (8% [0–17%] versus 19% [16–21%], P<0.05). There was no temporal trend for overall CFR and CM-specific CFR but declining HG- and MA- specific CFRs were observed.InterpretationThese data highlight that recent estimates of declining global malaria mortality are not replicated by improved outcomes for children hospitalized with SM. Significant geographic differences in the complication rates and subsequent CFRs exist and provide the first robust confirmation of lower CFRs in Melanesian children, perhaps due to less frequent HG.

Is the epidemiology of alkhurma hemorrhagic fever changing?: A three-year overview in Saudi Arabia.

BackgroundThe epidemiology of Alkhurma hemorrhagic fever disease is yet to be fully understood since the virus was isolated in 1994 in the Kingdom of Saudi Arabia.SettingPreventive Medicine department, Ministry of Health, Kingdom of Saudi Arabia.DesignRetrospective analysis of all laboratory confirmed cases of Alkhurma hemorrhagic fever disease collected through active and passive surveillance from 1st-January 2009 to December, 31, 2011.ResultsAlkhurma hemorrhagic fever (AHFV) disease increased from 59 cases in 2009 to 93 cases in 2011. Cases are being discovered outside of the region where it was initially diagnosed in Saudi Arabia. About a third of cases had no direct contact with animals or its products. Almost all cases had gastro-intestinal symptoms. Case fatality rate was less than 1%.ConclusionsFindings in this study showed the mode of transmission of AHFV virus may not be limited to direct contact with animals or its products. Gastro-intestinal symptoms were not previously documented. Observed low case fatality rate contradicted earlier reports. Close monitoring of the epidemiology of AHFV is recommended to aid appropriate diagnosis. Housewives are advised to wear gloves when handling animals and animal products as a preventive measure.

Executive Summary: Heart Disease and Stroke Statistics—2014 Update

Author(s): Go, Alan S; Mozaffarian, Dariush; Roger, Veronique L; Benjamin, Emelia J; Berry, Jarett D; Blaha, Michael J; Dai, Shifan; Ford, Earl S; Fox, Caroline S; Franco, Sheila; Fullerton, Heather J; Gillespie, Cathleen; Hailpern, Susan M; Heit, John A; Howard, Virginia J; Huffman, Mark D; Judd, Suzanne E; Kissela, Brett M; Kittner, Steven J; Lackland, Daniel T; Lichtman, Judith H; Lisabeth, Lynda D; Mackey, Rachel H; Magid, David J; Marcus, Gregory M; Marelli, Ariane; Matchar, David B; McGuire, Darren K; Mohler, Emile R; Moy, Claudia S; Mussolino, Michael E; Neumar, Robert W; Nichol, Graham; Pandey, Dilip K; Paynter, Nina P; Reeves, Matthew J; Sorlie, Paul D; Stein, Joel; Towfighi, Amytis; Turan, Tanya N; Virani, Salim S; Wong, Nathan D; Woo, Daniel; Turner, Melanie B; American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Central and statistical data monitoring in the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial

Background The purpose of monitoring in clinical trials is to ensure the rights, safety, and well-being of trial patients and the accuracy of the trial data. In the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, which recruited over 20,000 adult trauma patients worldwide, the nature and extent of monitoring was based on a risk assessment undertaken before recruitment started. Purpose We report the methods used for central and statistical monitoring in the CRASH-2 trial and explain how central monitoring was used to target on-site investigations. Methods To ensure that trial participants met the inclusion criteria, we monitored event rates for the primary (death) and secondary outcomes (blood transfusion given). We monitored four quantitative variables (systolic blood pressure (SBP), heart rate (HR), respiratory rate, and capillary refill time) as indicators of the severity of bleeding. We used the coefficient of variation (CV) to identify sites with too much or too little variability. To ensure the accuracy of the data on side effects, we monitored thromboembolic events at each site. Sites with higher or lower than expected event rates were identified for further evaluation. Results A total of 274 sites recruited patients: 145 sites recruited ≥20; patients, and 52 sites recruited ≥100 patients. Sites with low case fatality and low blood transfusion rates were found to be including patients with relatively mild haemorrhage. One site with a high rate of thromboembolic events was found to be using clinical judgement alone. Measurements of SBP and HR varied by about one-fifth of their average value, and capillary refill time measurements varied by around one-third of their average; between-site variation was lowest for blood pressure. Limitations A comparison of mean and median CV indicated that the distributions are slightly skewed to the right. Our simple approach to calculating 95% confidence intervals for the CV may be improved by using a logarithmic transformation of CV for each variable. Conclusions Central and statistical monitoring of data can be used to monitor clinical trials, particularly large, pragmatic, international trials where 100% on-site monitoring is neither necessary nor cost-effective. In the CRASH-2 trial, re-education about trial protocol and the development of guidance helped resolve the issues identified during monitoring.

Factors Influencing the Decline in Stroke Mortality

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden. Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions. The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Barrow-in-Furness: a large community legionellosis outbreak in the UK.

A community outbreak of legionellosis occurred in Barrow-in-Furness, Cumbria, during July and August 2002. A descriptive study and active case-finding were instigated and all known wet cooling systems and other potential sources were investigated. Genotypic and phenotypic analysis, and amplified fragment length polymorphism of clinical human and environmental isolates confirmed the air-conditioning unit of a council-owned arts and leisure centre to be the source of infection. Subsequent sequence-based typing confirmed this link. One hundred and seventy-nine cases, including seven deaths [case fatality rate (CFR) 3·9%] were attributed to the outbreak. Timely recognition and management of the incident very likely led to the low CFR compared to other outbreaks. The outbreak highlights the responsibility associated with managing an aerosol-producing system, with the potential to expose and infect a large proportion of the local population and the consequent legal ramifications and human cost.

A population-based analysis of children with pneumonia among intensive care units in Taiwan

Pneumonia is a major diagnosis in children that requires intensive care and is a major cause of mortality in critically ill children. A survey on current epidemiology and case fatality-associated conditions is crucial for the care of critically ill children with pneumonia in an intensive care unit (ICU). The sex, age, seasonality of admission, area of distribution, and case fatality rate of children younger than 18 years who had pneumonia and were admitted to an ICU during the period 2006-2010 were obtained from the National Health Insurance Research Database (NHIRD) of Taiwan. The enrolled children were grouped by age (0-2 years, 3-5 years, 6-11 years, and 12-17 years). The need for invasive procedures such as endotracheal tube (ET) insertion, mechanical ventilation (MV), tracheostomy, central venous catheter (CVC) insertion, chest tube insertion/drainage, chest surgery, and extracorporeal membranous oxygenation (ECMO) were analyzed to clarify their association with case fatality in critically ill children with pneumonia. Of the 12,577 children enrolled, 7131 (56.7%) were boys and 5446 (43.3%) were girls. The younger age groups had more cases of pneumonia, but less often required invasive procedures. Children 0-2 years old (n = 6083) accounted for approximately one-half (48.4%) of all enrolled children. This group had the lowest case fatality rate (3.1%; 187/6083 children) and lowest need for invasive procedures (31.1%; 1892/6083 children), whereas children in the 12-17 year-old group had the highest case fatality rate (9.9%; 140/1417 children) and the highest need for invasive procedures (59.8%; 847/1417 children) (p < 0.001). The percentage of pneumonia cases was highest in the spring (30.1%) and lowest in the summer (21.7%). The invasive procedures associated with case fatality were ET/MV (OR, 14.31; p < 0.001), CVC insertion (OR, 7.46; p < 0.001), ECMO intervention (OR, 4.59; p < 0.001), and chest tube insertion/drainage (OR, 1.87; p < 0.001). The number of cases of pneumonia that required ICU admission was greater among younger children than among older children. Factors associated with the higher case fatality rate included older age at presentation, the need for invasive procedures (e.g., ET/MV, CVC insertion, chest tube insertion/drainage, and ECMO), underlying comorbidities and complications.

Impact of gender–age interaction on the outcome of ischemic stroke in an Italian cohort of patients treated according to a standardized clinical pathway

BackgroundStroke outcome has been reported as worse in women, especially in terms of disability. As for mortality, the data are conflicting, with some reports suggesting a female advantage. Our objective was to explore such issues in an Italian cohort of patients managed by a standardized clinical pathway (CPW) and, as such, homogeneous in terms of clinical management. MethodsData from a cohort of 1993 patients (987 women and 1006 men) with first-ever ischemic stroke, consecutively referred to an in-hospital Clinical Pathway Program from January 1, 2001 to December 31, 2009, were retrospectively analyzed. The relationship between female gender and one-month outcome was assessed with adjustment for age, stroke severity and premorbid disability. ResultsThe outcome was worse in women in terms of disability (age-adjusted odds ratio 2.03, 95% CI 1.69–2.46), while no difference was found for mortality. In multivariate models, female gender turned out to be associated with a lower case-fatality rate (adjusted hazard ratio 0.65, 95% CI 0.48–0.89, P=0.007), whereas the odds ratio for disability decreased but remained significant (OR 1.30; 95% CI 1.01–1.69). We found a significant interaction between gender and age in the case-fatality rate, and a female survival advantage was apparent only below 50years. ConclusionsOur study confirms the excess risk of disability after stroke in women, although it is mostly explained by the occurrence of the most severe clinical syndromes. As for mortality, female gender seems to play a protective role, at least in the short-term and in younger patients.

Case Fatality Rate with Vena Cava Filters in Hospitalized Stable Patients with Cancer and Pulmonary Embolism

BackgroundIn view of the high risk of pulmonary embolism in patients with cancer, we tested the hypothesis that stable patients with pulmonary embolism who have cancer might be a subset of patients who would show a lower case fatality rate with vena cava filters than without filters. MethodsStable patients with pulmonary embolism and cancer at discharge from short-stay hospitals throughout the US from 1998-2009 were identified from the Nationwide Inpatient Sample. Patients with pulmonary embolism who had a diagnostic code for shock, ventilatory support, thrombolytic therapy, or pulmonary embolectomy were excluded because such patients have been shown to have lower case fatality rate with filters. ResultsIn-hospital all-cause case fatality rate was lower with vena cava filters in stable patients with pulmonary embolism and solid malignant tumors providing they were aged >30 years, but there was variability according to type of tumor and age of patient. On average, case fatality rate among those >30 years with filters was 7070 of 69,350 (10.2%) (95% confidence interval, 10.0-10.4) versus 36,875 of 247,125 (14.9%) (95% confidence interval, 14.8-15.1) without filters (P <.0001) (relative risk 0.68). Among stable patients with hematological malignancies, case fatality rate, except in the elderly, was higher among those with vena cava filters than those without filters. ConclusionStable patients with pulmonary embolism and solid malignant tumors who are older than age 30 years appear to be a subset of patients with pulmonary embolism who would benefit from vena cava filters, but this needs to be tested prospectively.

Effect of ribotype on all-cause mortality following Clostridium difficile infection

Clostridium difficile infection (CDI) is significantly associated with subsequent all-cause mortality. Although a number of studies have investigated mortality associated with CDI, few have compared all-cause mortality between ribotypes. We aimed to estimate all-cause mortality following CDI and to investigate the relationship between mortality, ribotype and other available variables. We undertook a retrospective cohort study. All patients with toxin-positive CDI in North East England between July 2009 and June 2011 were matched to death registration data. Differences in all-cause 30-day case fatality were explored using Poisson regression with robust error variances. For survival analysis, an accelerated failure time model with generalized gamma distribution was chosen. In total, 1426 patients were included. All-cause case fatality was 10.2%, 16.4%, 25.7% and 38.1% at 7, 14, 30 and 90 days respectively. In multivariate analysis, ribotype 027 (risk ratio: 1.34; 95% confidence interval: 1.02-1.75) and ribotype 015 (0.46; 0.26-0.82) were significantly associated with higher and lower all-cause 30-day case fatality rates, respectively. In survival analysis, only ribotype 015 had significantly lower predicted mortality (P=0.008). Patients whose infection was hospital-acquired had significantly higher predicted mortality (P<0.001). This is the first population-based study of comparative mortality between multiple ribotypes. Our study identified a high rate of all-cause mortality following CDI. We found evidence of variability in mortality between ribotypes in this cohort with mortality significantly higher for ribotype 027 at 30 days following diagnosis and significantly lower for ribotype 015.

Trends in Mortality and Early Central Line Placement in Septic Shock

Trends in Mortality and Early Central Line Placement in Septic Shock

Treatment of Unstable Pulmonary Embolism in the Elderly and Those with Comorbid Conditions

BackgroundAlthough the in-hospital case fatality rate is lower in unstable patients with pulmonary embolism who receive thrombolytic therapy, less than one third receive it. The purpose of this investigation is to try to assess why most unstable patients fail to receive thrombolytic therapy and whether evidence might support a more aggressive approach. MethodsData were obtained from the Nationwide Inpatient Sample 1999-2008. ResultsFewer unstable patients with pulmonary embolism accompanied by comorbid conditions received thrombolytic therapy than patients with no comorbid conditions, 11,670 of 60,100 (19.4%) vs 9710 of 12,130 (80.0%) (P<.0001). Fewer patients aged>60 years received thrombolytic therapy than patients aged≤60 years, both among those with comorbid conditions, 6330 of 37,320 (17.0%) vs 5340 of 22,780 (23.4%) (P<.0001), and among those without comorbid conditions, 3560 of 5060 (70.4%) vs 6150 of 7070 (87.0%) (P<.0001). However, even among elderly patients and those with comorbid conditions, the case fatality rate was lower with thrombolytic therapy. The odds ratio of in-hospital death (0.11-0.62) favored thrombolytic therapy irrespective of age or comorbidity. ConclusionUnstable patients with pulmonary embolism were less likely to receive thrombolytic therapy if they were elderly or had comorbid conditions, but those who received thrombolytic therapy had a lower in-hospital case fatality rate irrespective of age or comorbid conditions. The cautious approach of withholding thrombolytic therapy in those who might have major bleeding might not be the safest approach in terms of mortality and needs to be prospectively evaluated.

Vena cava filters in hospitalised patients with chronic obstructive pulmonary disease and pulmonary embolism

In view of the high case fatality rates of patients with chronic obstructive pulmonary disease (COPD) who have pulmonary embolism (PE) we speculated that such patients might benefit from vena cava filters. To test this hypothesis we assessed the database of the Nationwide Inpatient Sample. From 1998-2009, 440,370 patients were hospitalised with PE and COPD who were not in shock or ventilator-dependent and did not receive thrombolytic therapy or pulmonary embolectomy. In-hospital all-cause case fatality rate among those with filters was 5,890 of 68,800 (8.6%) (95% confidence interval [CI] = 8.4-8.8) compared with 38,960 of 371,570 (10.5%) (95% CI = 10.4-10.6) (p<0.0001) who did not receive filters. Case fatality rate was age-dependent. Only those who were older than aged 50 years had a lower in-hospital all-cause case fatality rate with filters. Among such patients, absolute risk reduction was 2.1% (95% CI = 1.9-2.3). The greatest reduction of case fatality rate with vena cava filters was shown in patients >aged 80 years, 11,720 of 81,600 (14.4%) compared with 1,570 of 17,220 (9.1%) (p<0.0001). In conclusion, a somewhat lower in-hospital all-cause case fatality rate was shown with vena filters in stable patients with PE >aged 50 years who also had COPD. The benefit was greatest in elderly patients. The benefit in terms of a decreased case fatality rate would seem to outweigh the risks of vena cava filters in such patients.